Guidance for rationalising early pregnancy services in the evolving coronavirus (COVID-19) pandemic - Information for healthcare professionals ...
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Guidance for rationalising early
pregnancy services in the evolving
coronavirus (COVID-19) pandemic
Information for healthcare professionals
Version 1.2: Published Friday 15 May 2020
1Summary of updates
Version Date Summary of changes
1.1 21.04.20 5.1: Added ‘Evidence of a septic miscarriage - signs of infection (e.g. temperature,
offensive smelling discharge) in association with symptoms of retained pregnancy
tissue (pain and/or bleeding)’ as a reason for assessment within 24 hours. Added
additional risk factors for ectopic pregnancy.
1.1 21.4.20 10: Section and recommendation added ‘Administer anti-D prophylaxis to women
who have a surgical procedure, including manual vacuum aspiration, or have a late
miscarriage, in line with British Society of Haematology and NICE guidelines.’
1.2 15.05.20 1: Section on BAME advice added ‘When reorganising services, units should be
particularly cognisant of emerging evidence that black, Asian and minority ethnic
group (BAME) individuals are at particular risk of developing severe and life-
threatening COVID-19. Clinicians should encourage women to seek early advice if
they are concerned about symptoms suggestive of COVID-19. There is extensive
evidence on the inequality of experience and outcomes for BAME women during
pregnancy in the UK. Particular consideration should be given to the experience of
women of BAME background and of lower socioeconomic status, when evaluating
the potential or actual impact of any service change.’
1. Introduction
This guidance is to support early pregnancy services during the evolving COVID-19 pandemic. It outlines
which elements of care should be prioritised and recommends modifications to early pregnancy care, given
national recommendations for social distancing of pregnant women.
When reorganising services, units should be particularly cognisant of emerging evidence that black, Asian
and minority ethnic group (BAME) individuals are at particular risk of developing severe and life-threatening
COVID-19. This evidence is detailed in the RCOG coronavirus in pregnancy guidance. Clinicians should
encourage women to seek early advice if they are concerned about symptoms suggestive of COVID-19. There
2is extensive evidence on the inequality of experience and outcomes for BAME women during pregnancy in the
UK. Particular consideration should be given to the experience of women of BAME background and of lower
socioeconomic status, when evaluating the potential or actual impact of any service change.
2. Screening of women presenting to early pregnancy
services
All women should be asked to attend appointments alone or as per local visiting restrictions during the
COVID-19 pandemic.
Where a woman requires a consultation due to the need for physical examination or a scan, a system should
be in place for evaluating whether she has symptoms that are suggestive of COVID-19, or if she meets the
current ‘stay at home’ guidance. For similar advice in Scotland, see here. This may be a telephone call before the
appointment or an assessment at entry to the department.
If a woman attends an appointment but describes symptoms, she should be advised to return home immediately
if clinically stable. A member of clinical staff should then make contact with the woman to risk assess whether
an urgent modified appointment is required, or whether the appointment can be conducted via telephone
consultation.
If an urgent assessment in person or ultrasound scan is required for a woman with confirmed or suspected
COVID-19 infection, a room and an ultrasound machine should be designated for this.
All women with a possible COVID-19 infection must be highlighted to all members of the gynecology, maternity,
nursing and anaesthetic teams. If the woman requires admission to hospital, the location will depend on the
reason for admission and local policy, until COVID-19 testing confirms her status.
33. Delaying appointments where appropriate
3.1 Pre-existing appointments
A review of the clinical urgency of currently held appointments should be made by the clinical team and
women will be contacted as necessary.
3.2 In home isolation for suspected or confirmed COVID-19
If delay is clinically appropriate (Table 5.1), care should be provided via a telephone consultation. If urgent care
is required, attendance to hospital should be preceded by a phone call to alert the local unit.
3.3 Rebooking appointments
The local service should decide how best to manage rebooking of appointments (blood tests and/or scans)
and the woman should be informed of her new appointment.
3.4 Failsafe
A local failsafe should be established to ensure that appointments for all women are reviewed and, if reoffered,
that they are attended. Follow local protocols for follow up of women who do not attend.
4. Coordinating your local early pregnancy unit
As well the usual day-to-day requirements for running an early pregnancy unit, we recommend the following:
• Managers should be aware that staff (or members of their family) may become unwell during the
pandemic; daily review of the case load, staffing and contingency planning is advised.
• If a pregnant woman is diagnosed with COVID-19, this should be reported to the UK Obstetric
Surveillance System.
4• Multi-disciplinary team (MDT) meetings: we highly encourage units to conduct a minimum of a weekly
MDT meeting (can be arranged using an online meeting platform).
5. Ensuring that early pregnancy units are used
appropriately
Women should not attend early pregnancy units without a telephone triage consultation with an
experienced clinician, using a locally agreed structure for triage.
Local units following a walk-in model should adopt a robust triage-based system with a dedicated phone
number for referrals. Appropriate triage is essential to allow prioritisation of those at high risk of complications,
mainly ectopic pregnancy, where hospital visits will be safer than telephone-based consultations.
The inevitable reduction in resources and capacity, as well as the aim to minimise hospital attendance for social
distancing of pregnant women, have led to a recommendation of one of the following three options (Table 5.1):
• Scans and/or visits that need to be undertaken without delay;
• Scans and/or visits that can be delayed without affecting clinical care;
• Scans and/or visits that can be avoided for the duration of the pandemic.
Table 5.1 Recommended triage and action for early pregnancy units
Problem Recommended action
Abdominal or pelvic pain (no previous scan) Offer scan within 24 hours
Heavy bleeding for more than 24 hours and systemic Offer scan within 24 hours
symptoms of blood loss
Evidence of a septic miscarriage - signs of infection (e.g. Offer assessment within 24 hours
temperature, offensive smelling discharge) in association (Note a temperature may also be associated with
with symptoms of retained pregnancy tissue (pain and/or COVID-19 infection.)
bleeding).
5Pain and/or bleeding together with pre-existing risk Offer scan within 24 hours if location of pregnancy not
factors for ectopic pregnancy: known
• Previous ectopic pregnancy
• Previous fallopian tube, pelvic or abdominal
surgery,
• History of sexually transmitted infections / pelvic
inflammatory disease
• Use of an IUCD or IUS
• Use of assisted reproductive technology
• Current smoker or age over 40
Moderate bleeding Telephone consultation with experienced clinician – urine
pregnancy test (UPT) in one week:
• Negative – no follow-up
• Positive – offer telephone consultation +/- repeat
UPT in one further week or scan
Heavy bleeding that has resolved Telephone consultation with experienced clinician – UPT in
one week:
• Negative – no follow-up
• Positive – offer telephone consultation +/- repeat
UPT in one further week or scan
Reassurance Telephone consultation with experienced clinician – no
routine scan
Previous miscarriage(s) Telephone consultation with experienced clinician – no
routine scan
Light bleeding with/without pain that is not troublesome Telephone consultation with experienced clinician – no
to patient routine scan
66. Management of miscarriage
Women who experience a miscarriage should be cared for in accordance with local protocols. There should
be an effort to reduce inpatient admission due to COVID-19: offer expectant management for incomplete
miscarriage and consider medical management / use of manual vacuum aspiration for missed miscarriage.1
Counselling should be offered and performed over the phone where possible.
The availability of surgery will need to be reviewed locally on a daily basis and if surgical management is
indicated, appropriate precautions related to personal protective equipment (PPE) should be taken in line with
national Health Protection guidance.2
Regional anaesthesia may be considered in COVID-19 positive women to reduce the risk to staff from general
anaesthetic, which is an aerosol-generating procedure.
Outpatient management is preferred where appropriate. Provide advice on analgesia and the process of
miscarrying, in order to support women to remain at home.
Those who have expectant or medical management should not be offered further routine ultrasound scans but
asked to repeat a hCG urine test after three weeks. If this is positive, they should be advised to call the early
pregnancy unit to arrange further care.
Units should aim to provide telephone consultation to women three weeks following their miscarriage to
assess physical and emotional well-being, if resources are available.
7. Intrauterine pregnancy of unknown viability
No further ultrasound scans are recommended.
If the ultrasound scan findings are consistent with menstrual dates no follow up is required.
If findings are not consistent with menstrual dates, explain the risk of miscarriage and consider telephone
follow-up in two weeks.
78. Management of pregnancy of unknown location
Use serial beta human chorionic gonadotrophin (beta-hCG) monitoring +/- progesterone at presentation, as
per local protocol, to triage women into one of:
• Low risk failing PUL:
o Pregnancy test at home in two weeks
o Contact local unit if positive
• Low risk intrauterine pregnancy:
o Scan in one week to confirm location and viability
• High risk for ectopic pregnancy:
o return for a repeat beta-hCG and/or scan in a further 48 hours
The M6 model can be used to help with decision making in women with PUL to reduce the number of hospital
visits due to COVID-19. It is available at www.earlypregnancycare.co.uk.3,4
9. Management of ectopic pregnancy
Women with ectopic pregnancy should be cared for in accordance to local protocols with an emphasis on
conservative management if possible.
9.1 Expectant management
Ensure follow up is appropriate with an individualised approach. There is a need to balance safety with reducing
hospital attendance as much as possible in order to reduce the risk of COVID-19 to women, staff and other
patients.
8When performing beta-HCG monitoring, where possible, repeat levels on a weekly basis. Repeat ultrasound
scans should not be routine unless clinically indicated.
9.2 Medical management with single dose methotrexate
It is likely the detrimental effects of methotrexate in COVID-19 are minimal in well women.
As with any ectopic pregnancy, women with suspected /confirmed COVID-19 should be discussed at the early
pregnancy unit multi-disciplinary team (MDT) meeting. Administration of methotrexate must be discussed and
signed off by a senior clinician prior to treatment, and any ultrasound and beta-hCG levels reviewed carefully.
Severely unwell women with COVID-19 and ectopic pregnancy will need to be discussed at an MDT with
medical and anaesthetic input.
In addition to routine information giving when offering the choice of methotrexate, inform the woman that:
• Methotrexate is a mildly immunosuppressive medication but there is not thought to be a significant risk
in the case of COVID-19 at the dose used to manage ectopic pregnancy. 1
• There is a theoretical risk that any immunosuppressive medication can make you more vulnerable to
viral illness.
• E xpert opinion is that the dose of methotrexate given for medical management of ectopic pregnancy is
unlikely to increase vulnerability to COVID-19 and does not require home shielding after administration.
• Medical management of ectopic pregnancy avoids hospital admission and surgery, potentially lowering
overall exposure to COVID-19.
9.3 Surgical management
Surgical management of ectopic during the coronavirus pandemic should only be considered following
senior review of the ultrasound scan, beta-hCG and clinical findings and if no other management option is
safely feasible.
The BSGE/RCOG support the use of laparoscopy, but with necessary caution.5 Given the limited evidence
on the safety of laparoscopy, any laparoscopic surgery should only be undertaken with strict precautions taken
9to filter any CO2 escaping into the operating theatre and the theatre staff wearing appropriate PPE. Mini-
laparotomy can be considered as an alternative to laparoscopy if these strict precautions cannot be confidently
met.
10. Anti-D prophylaxis
Administer anti-D prophylaxis to women who have a surgical procedure, including manual vacuum aspiration,
or have a late miscarriage, in line with British Society of Haematology6 and NICE7 guidelines.
If miscarriage occurs at home, and having to check RhD status would require an additional visit for the woman,
it could be omitted if the risk from COVID-19 outweighs the benefit of receiving anti-D immunoglobulin.
Providers should discuss the absence of evidence with women and engage in shared decision making.
11. Management of nausea and vomiting in
pregnancy
If a woman has nausea and vomiting in pregnancy, she should be assessed over the phone using the PUQE
scoring system and advised regarding anti-emetics, as per local protocol.8 Local arrangements for issuing
prescriptions remotely after a telephone consultation, where these do not already exist, should be put in place.
Services should plan how to best configure their local protocols during the coronavirus pandemic for those
women who require parenteral hydration. This might include hospital at home, day-case or inpatient admission
services. Vomiting is a potential risk for transmission, and appropriate.
The rare possibility of a molar pregnancy should be considered in women with hyperemesis gravidarum and
other symptoms such as vaginal bleeding. In the event of routine dating ultrasound assessments being delayed,
women should be offered assessment in early pregnancy departments if gestational trophoblastic disease is
suspected.
10References
1. National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial
management. Guideline. NICE. 2019
2. COVID-19: Infection, prevention and control guidance 2020 Available from: https://www.gov.
uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/wuhan-
novelcoronavirus-wn-cov-infection-prevention-and-control-guidance [Accessed 05 January 2020].
3. Bobdiwala S, Saso S,Verbakel JY, Al-Memar M,Van Calster B,Timmerman D, Bourne T. Diagnostic protocols
for the management of pregnancy of unknown location: A systematic review and meta-analysis. BJOG.
2019 Jan;126(2):190-198, doi: 10.1111/1471-0528.15442.
4. Bobdiwala S, Christodoulou E, Farren J, Mitchell-Jones N, Kyriacou C, Al-Memar M, Ayim F, Chohan B, Kirk
E, Abughazza O, Guruwadahyarhalli, Guha S, Vathanan V, Bottomley C, Gould D, Stalder C, Timmerman D,
Van Calster B, Bourne T. Triaging women with pregnancy of unknown location using two-step protocol
including M6 model: clinical implementation study. UOG. 2019 August 6, doi: 10.1002/uog.20420.
5. British Society of Gynaecological Endoscopy. Joint RCOG/BSGE statement on gynaecological laparoscopic
procedures and COVID-19. 2020
6. H. Qureshi, E. Massey, D. Kirwan, T. Davies, S. Robson, J. White, J. Jones, S. Allard. BCSH guideline for
the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn.
2014 doi: 10.1111/tme.12091
7. National Institute for Care Excellence. NICE Guideline 126: Ectopic pregnancy and miscarriage: diagnosis
and initial management. Apr 2019. Available from: https://www.nice.org.uk/guidance/ng126/chapter/
Recommendations#anti-d-rhesus-prophylaxis [Accessed 13 Apr 2020]
8. Royal College of Obstetricians and Gynaecologists.The Management of Nausea and Vomiting of Pregnancy
and Hyperemesis Gravidarum Green top guideline No 69. 2016 Available from https://www.rcog.org.uk/
globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf.
11Appendix 1: Summary
Positive urine pregnancy test
Pelvic pain - no Heavy bleeding Risk factors Moderable Asymptomatic - Asymptomatic Light bleeding
previous scan for > 24 of ectopic bleeding or for reassurance - history of +/-pain not
hours and pregnancy heavy bleeding previous troublesome to
symptomatic of + pain +/- that has settled miscarriage patient
anaemia bleeding
Offer USS Offer USS Offer USS Wait, repeat Not for Not for Not for
within 24 hours within 24 hours within 24 hours UPT 1 week USS. Refer USS. Refer scan. Refer
to antenatal to antenatal to antenatal
services services services
If UPT + offer To call if
telephone symptoms
consultation +/- persist/recur
repeat UPT in
1 further week
or USS
Obstetric review at 36 weeks’ to plan birth
12Appendix 2: Guidance for management of early pregnancy PUV - Pregnancy of unknown viability
PUL - Pregnancy of unknown location
complications during COVID-19 pandemic EPU - Early Pregnancy Unit
PPE - Personal protective equipment
UPT - Urinary pregnancy test
A&E / GP / Other referrals MVA - Manual vacuum aspiration
Telephone triage (dedicated number in the day-time, and oncall doctor at night or weekend)
Decide on COVID-19 risk Decide on urgency
High risk for Consult by telephone only See within 7 days if See very soon (within 4
Apparent low risk
COVID-19 or (no need for scan) necessary hours if urgent; otherwise
for COVID-19 within 24 hours) + scan
confirmed case
Light PV bleeding +/- mild Moderate PV bleeding, or Abdominal or pelvic pain in early pregnancy;
Telephone advice or Telephone advice or see pain heavy PV bleeding that has any symptoms of ectopic pregnancy + risk
see woman in EPU woman in a dedicated Hyperemesis settled and UPT remains + factor(s) for ectopic pregnancy; excessive
COVID-19 area bleeding in early pregnancy
Use COVID-19
Use appropriate specific USS
PPE machine; Pelvic ultrasound
use appropriate PPE
No further scans
PUV UPT in 2 weeks Live pregnancy or PUV
Miscarriage Expectant management
Incomplete: Expectant
management or methotrexate
Ectopic pregnancy
Missed: Medical PUL or laparoscopy or
management or MVA laparotomy
PUL use M6 model Use BSGE/RCOG
www.earlypregnancycare.co.uk guidelines for laparoscopy
13Authors
Tom Bourne, Imperial College, AEPU, Tommy’s National Centre for
Miscarriage Research and ISUOG
Chris Kyriacou, Imperial College, Tommy’s National Centre for Miscarriage
Research
Arri Coomarasamy, University of Birmingham and Tommy’s National Centre
of Miscarriage Research
Emma Kirk, Royal Free Hospital, AEPU and ESHRE early pregnancy SIG
George Condous, University of Sydney and ASUM
Mathew Leonardi, University of Sydney
Maya Al-Memar, Imperial College and Tommy’s National Centre of
Miscarriage Research
Rachel Small, Birmingham Heartland Hospital and AEPU
Eddie Morris, RCOG
Pat O’Brien, RCOG
Gemma Goodyear, RCOG Obstetric Fellow
Jen Jardine, RCOG Obstetric Fellow
Sophie Relph, RCOG Obstetric Fellow
14DISCLAIMER: The Royal College of Obstetricians and Gynaecologists (RCOG) has produced this
guidance as an aid to good clinical practice and clinical decision-making. This guidance is based on
the best evidence available at the time of writing, and the guidance will be kept under regular review
as new evidence emerges. This guidance is not intended to replace clinical diagnostics, procedures
or treatment plans made by a clinician or other healthcare professional and RCOG accepts no
liability for the use of its guidance in a clinical setting. Please be aware that the evidence base for
COVID-19 and its impact on pregnancy and related healthcare services is developing rapidly and the
latest data or best practice may not yet be incorporated into the current version of this document.
RCOG recommends that any departures from local clinical protocols or guidelines should be fully
documented in the patient’s case notes at the time the relevant decision is taken.
@RCObsGyn @rcobsgyn @RCObsGyn
Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ
T: +44 (0) 20 7772 6200 E: covid-19@rcog.org.uk W: rcog.org.uk Registered Charity No. 213280
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My doctor has confirmed that my appointment will take place at the hospital. Can I
take someone with me?
Your healthcare team will be able to advise you on your individual situation. You may be asked to come on your
own, or with just one accompanying person. Unfortunately, hospitals are unable to allow children to attend with
you during this time.
Will I be able to receive an ultrasound scan?
Unfortunately, early pregnancy units will not be able to offer ultrasound scans to provide reassurance to
women who have no symptoms. This will also be the case even if you have a previous history of miscarriage or
ectopic pregnancy.
For further information and advice in relation to ectopic pregnancy, please see the further information section
at the foot of this document.
What will happen if I do experience a miscarriage?
In the unfortunate event of a miscarriage, your care will depend on your individual situation.
• In most cases, it is likely that you will be asked to miscarry naturally without intervention. Your
healthcare team will make arrangements with you to ensure you can contact them should you have
any concerns during your recovery.
• You may alternatively receive outpatient medical management. Your healthcare team will make
arrangements with you to ensure your medical management is monitored.
• Where it is necessary, you may be asked to attend for surgery. Your healthcare team will discuss this
with you directly.
For further support and information in relation to miscarriage, please see the further information section at the
foot of this document.
18What if I am experiencing pregnancy related nausea and vomiting?
If you are experiencing nausea and vomiting in early pregnancy, you should inform your healthcare team, so that
they can arrange the right care for you.
Your care will depend on the level and impact of your symptoms. You may be offered anti-emetics (anti-
sickness medicine) as well as outpatient treatment including intravenous fluids. It is unlikely you will be admitted
to hospital in this situation, unless your symptoms become serious. See further information section at the foot
of this information.
Key points for you
• It is important to know that if you experience any health issues during early pregnancy that require you
to be seen by your healthcare professional, an appointment in an early pregnancy unit will be offered
and you will receive the care you need.
• Whilst hospitals are trying to minimise people entering in order to reduce the spread of the
COVID-19 virus and to limit the impact on services, they are organised in such a way that they are
able to provide all acute services.
• If you have symptoms that may be associated with miscarriage or ectopic pregnancy, it is very
important that you contact your healthcare professional. You will be able to speak with an experienced
member of your healthcare team on the phone before your appointment. They will be best placed to
advise you as to whether a visit to the hospital is necessary and to ensure you receive the care that
you need.
19Further information for you
You can find further information on the matters mentioned in this information at the following organisation
websites:
• Ectopic Pregnancy Trust
• Miscarriage Association
• RCOG Information for you: Hyperemesis Gravidaram (Pregnancy Sickness, nausea and vomiting)
• Pregnancy Sickness Support
You can also find all the latest guidance and information on how to protect you and your loved ones during
COVID-19 at the following organisation websites:
• Joint guidance from the Royal College of Obstetricians and Gynaecologists, the Royal College of
Midwives, Royal College of Paediatrics and Child Health, Public Health England and Health Protection
Scotland
• UK Government guidance explaining social distancing and self-isolation
• NHS 111 website
• NHS Inform in Scotland
• Public Health England
• Health Protection Scotland
• Mental Health Support
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